<?php
$random_mainimage = rand(1, 10);
$link = 'yes';
$page = '';
$image = 'reg';
?>

<?php

header("Expires: Mon, 26 Jul 1997 05:00:00 GMT"); // date in the past

header("Last-Modified: " . gmdate("D, d M Y H:i:s") . " GMT"); // always modified

header("Cache-Control: no-store, no-cache, must-revalidate"); // HTTP/1.1 

header("Cache-Control: post-check=0, pre-check=0", false); 

header("Pragma: no-cache"); // HTTP/1.0 



?>

<?php include ("db.php") ?>

<?php include ("phpmkrfn.php") ?>

<?php

ob_start();



// get action

$a = @$HTTP_POST_VARS["a"];

if (empty($a)) {

	$key = @$HTTP_GET_VARS["key"];

	if ($key <> "")	{

		$a = "C"; // copy record

	} else{

		$a = "I"; // display blank record

	}

}



// open connection to the database

$conn = mysql_connect(HOST, USER, PASS);

mysql_select_db(DB);

switch ($a) {

	case "C": // get a record to display

		$tkey = "" . $key . "";

		$strsql = "SELECT * FROM `NewHire` WHERE `id`=" . $tkey;

		$rs = mysql_query($strsql);

		if (mysql_num_rows($rs) == 0) {

			ob_end_clean();

			header("Location: newhirelist.php");

		} else {

			$row = mysql_fetch_array($rs);



		// get the field contents

			//$x_id = @$row["id"]; 

			$x_name = @$row["name"]; 
			
			$x_firstname = @$row["firstname"];
			
			$x_middleinitial = @$row["middleinitial"];
			
			$x_lastname = @$row["lastname"];

			$x_pres_addr = @$row["pres_addr"]; 
			
			$x_pres_addr2 = @$row["pres_addr2"];
			
			$x_pres_mth = @$row["pres_mth"];

			$x_pres_yrs = @$row["pres_yrs"]; 

			$x_prev_addr = @$row["prev_addr"]; 
			
			$x_prev_addr2 = @$row["prev_addr2"];
			
			$x_prev__mth = @$row["prev__mth"];

			$x_prev__yrs = @$row["prev__yrs"]; 

			$x_phone = @$row["phone"]; 
			
			$x_phone1 = @$row["phone1"];
			
			$x_phone2 = @$row["phone2"];
			
			$x_phone3 = @$row["phone3"];

			$x_ssn = @$row["ssn"]; 
			
			$x_ssn1 = @$row["ssn1"];
			
			$x_ssn2 = @$row["ssn2"];
			
			$x_ssn3 = @$row["ssn3"];

			$x_q1 = @$row["q1"]; 

			$x_q1_cmt = @$row["q1_cmt"]; 

			$x_q2 = @$row["q2"]; 

			$x_q2_cmt = @$row["q2_cmt"]; 

			$x_q3 = @$row["q3"]; 

			$x_q3_cmt = @$row["q3_cmt"]; 

			$x_pres_empl = @$row["pres_empl"]; 

			$x_pres_empl_addr = @$row["pres_empl_addr"]; 
			
			$x_pres_empl_addr2 = @$row["pres_empl_addr2"];

			$x_pres_empl_city = @$row["pres_empl_city"]; 
			
			$x_pres_empl_state = @$row["pres_empl_state"];
			
			$x_pres_empl_zip = @$row["pres_empl_zip"];

			$x_pres_empl_phone = @$row["pres_empl_phone"]; 
			
			$x_pres_empl_phone1 = @$row["pres_empl_phone1"];
			
			$x_pres_empl_phone2 = @$row["pres_empl_phone2"];
			
			$x_pres_empl_phone3 = @$row["pres_empl_phone3"];

			$x_pres_empl_yr_st = @$row["pres_empl_yr_st"]; 
			
			$x_pres_empl_yr_st_mth = @$row["pres_emp_yr_st_mth"];
			
			$x_pres_empl_yr_st_yr = @$row["pres_emp_yr_st_yr"];

			$x_pres_empl_yr_end = @$row["pres_empl_yr_end"]; 
			
			$x_pres_empl_yr_end_mth = @$row["pres_empl_yr_end_mth"];
			
			$x_pres_empl_yr_end_yr = @$row["pres_empl_yr_end_yr"];

			$x_res_empl_pay_st = @$row["res_empl_pay_st"]; 
			
			$x_pres_empl_pay_st_dol = @$row["pres_empl_pay_st_dol"];
			
			$x_pres_empl_pay_st_cen = @$row["pres_empl_pay_st_cen"];

			$x_pres_empl_pay_end = @$row["pres_empl_pay_end"]; 
			
			$x_pres_empl_pay_end_dol = @$row["pres_empl_pay_end_dol"];
			
			$x_pres_empl_pay_end_cen = @$row["pres_empl_pay_end_cen"];

			$x_pres_empl_title = @$row["pres_empl_title"]; 

			$x_pres_empl_super = @$row["pres_empl_super"]; 

			$x_pres_empl_reason = @$row["pres_empl_reason"]; 

			$x_prev_empl = @$row["pres_empl"]; 

			$x_prev_empl_addr = @$row["pres_empl_addr"]; 
			
			$x_prev_empl_addr2 = @$row["pres_empl_addr2"];

			$x_prev_empl_city = @$row["pres_empl_city"]; 
			
			$x_prev_empl_state = @$row["pres_empl_state"];
			
			$x_prev_empl_zip = @$row["pres_empl_zip"];

			$x_prev_empl_phone = @$row["pres_empl_phone"]; 
			
			$x_prev_empl_phone1 = @$row["pres_empl_phone1"];
			
			$x_prev_empl_phone2 = @$row["pres_empl_phone2"];
			
			$x_prev_empl_phone3 = @$row["pres_empl_phone3"];

			$x_prev_empl_yr_st = @$row["pres_empl_yr_st"]; 
			
			$x_prev_empl_yr_st_mth = @$row["pres_emp_yr_st_mth"];
			
			$x_prev_empl_yr_st_yr = @$row["pres_emp_yr_st_yr"];

			$x_prev_empl_yr_end = @$row["pres_empl_yr_end"]; 
			
			$x_prev_empl_yr_end_mth = @$row["pres_empl_yr_end_mth"];
			
			$x_prev_empl_yr_end_yr = @$row["pres_empl_yr_end_yr"];

			$x_prev_empl_pay_st = @$row["res_empl_pay_st"]; 
			
			$x_prev_empl_pay_st_dol = @$row["pres_empl_pay_st_dol"];
			
			$x_prev_empl_pay_st_cen = @$row["pres_empl_pay_st_cen"];

			$x_prev_empl_pay_end = @$row["pres_empl_pay_end"]; 
			
			$x_prev_empl_pay_end_dol = @$row["pres_empl_pay_end_dol"];
			
			$x_prev_empl_pay_end_cen = @$row["pres_empl_pay_end_cen"];

			$x_prev_empl_title = @$row["pres_empl_title"]; 

			$x_prev_empl_super = @$row["pres_empl_super"]; 

			$x_prev_empl_reason = @$row["pres_empl_reason"]; 
			
			$x_prev2_empl = @$row["pres_empl"]; 

			$x_prev2_empl_addr = @$row["pres_empl_addr"]; 
			
			$x_prev2_empl_addr2 = @$row["pres_empl_addr2"];

			$x_prev2_empl_city = @$row["pres_empl_city"]; 
			
			$x_prev2_empl_state = @$row["pres_empl_state"];
			
			$x_prev2_empl_zip = @$row["pres_empl_zip"];

			$x_prev2_empl_phone = @$row["pres_empl_phone"]; 
			
			$x_prev2_empl_phone1 = @$row["pres_empl_phone1"];
			
			$x_prev2_empl_phone2 = @$row["pres_empl_phone2"];
			
			$x_prev2_empl_phone3 = @$row["pres_empl_phone3"];

			$x_prev2_empl_yr_st = @$row["pres_empl_yr_st"]; 
			
			$x_prev2_empl_yr_st_mth = @$row["pres_emp_yr_st_mth"];
			
			$x_prev2_empl_yr_st_yr = @$row["pres_emp_yr_st_yr"];

			$x_prev2_empl_yr_end = @$row["pres_empl_yr_end"]; 
			
			$x_prev2_empl_yr_end_mth = @$row["pres_empl_yr_end_mth"];
			
			$x_prev2_empl_yr_end_yr = @$row["pres_empl_yr_end_yr"];

			$x_prev2_empl_pay_st = @$row["res_empl_pay_st"]; 
			
			$x_prev2_empl_pay_st_dol = @$row["pres_empl_pay_st_dol"];
			
			$x_prev2_empl_pay_st_cen = @$row["pres_empl_pay_st_cen"];

			$x_prev2_empl_pay_end = @$row["pres_empl_pay_end"]; 
			
			$x_prev2_empl_pay_end_dol = @$row["pres_empl_pay_end_dol"];
			
			$x_prev2_empl_pay_end_cen = @$row["pres_empl_pay_end_cen"];

			$x_prev2_empl_title = @$row["pres_empl_title"]; 

			$x_prev2_empl_super = @$row["pres_empl_super"]; 

			$x_prev2_empl_reason = @$row["pres_empl_reason"]; 

			$x_emp_gaps = @$row["emp_gaps"]; 

			$x_accomplish = @$row["accomplish"]; 

			$x_agree = @$row["agree"]; 

			$x_signature = @$row["signature"]; 

			$x_date = @$row["date"]; 
			
			$x_date_mth = @$row["date"];
			
			$x_date_day = @$row["day"];
			
			$x_date_yr = @$row["yr"];

		}

		mysql_free_result($rs);

		break;

	case "A": // add



	// PDF GENERATION START



	include ('class.ezpdf.php');



	$pdf =& new Cezpdf();

	$pdf->selectFont('./fonts/Helvetica.afm');

	$pdf->ezSetMargins(50,30,30,30);



		$pdf->ezText('Unique PEO NEW HIRE FORM (Texas)',20);

		$pdf->ezText('',10);

		$pdf->ezText('Name: '.$x_name,10);

		$pdf->ezText('Previous Address: '.$x_pres_addr,10);

		$pdf->ezText('How long have you lived there? '.$x_pres_yrs,10);

		$pdf->ezText('Present Address: '.$x_prev_addr,10);

		$pdf->ezText('How long have you lived there? '.$x_prev__yrs,10);

		$pdf->ezText('PHone Number: '.$x_phone,10);

		$pdf->ezText('Social Security Number: '.$x_ssn,10);

		$pdf->ezText('',10);

		$pdf->ezText('Have you ever worked for this Company before? '.$x_q1,10);

		$pdf->ezText('Details: '.$x_q1_cmt,10);

		$pdf->ezText('',10);

		$pdf->ezText('Have you ever pled guilty or no contest to, or been convicted of any midemenor or felony? '.$x_q2,10);

		$pdf->ezText('Details: '.$x_q2_cmt,10);

		$pdf->ezText('',10);

		$pdf->ezText('Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial? '.$x_q3,10);

		$pdf->ezText('Detials: '.$x_q3_cmt,10);

		$pdf->ezText('',10);

		$pdf->ezText('RECORD OF PREVIOUS EMPLOYMENT',10);

		$pdf->ezText('',10);

		$pdf->ezText('Please list the names of your previous emplolyers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business refernece under emplyment gaps.',10);

		$pdf->ezText('',10);

		$pdf->ezText('Present or Last Employer: '.$x_pres_empl,10);

		$pdf->ezText('Address'.$x_pres_empl_addr,10);

		$pdf->ezText('City, State, Zip Code'.$x_pres_empl_city,10);

		$pdf->ezText('Telephone'.$x_pres_empl_phone,10);

		$pdf->ezText('Employed from (mo/yr) '.$x_pres_empl_yr_st.' to '.$x_pres_empl_yr_end,10);

		$pdf->ezText('Pay Start: '.$x_res_empl_pay_st,10);

		$pdf->ezText('Pay Final: '.$x_pres_empl_pay_end,10);

		$pdf->ezText('Your Title or Position'.$x_pres_empl_title,10);

		$pdf->ezText('Name and Title of Last Supervisor'.$x_pres_empl_super,10);

		$pdf->ezText('Exact Reason for Leaving:',10);

		$pdf->ezText(''.$x_pres_empl_reason,10);

		$pdf->ezText('',10);

		$pdf->ezText('Previous Employer'.$x_prev_empl,10);

		$pdf->ezText('Address'.$x_prev_empl_addr,10);

		$pdf->ezText('City, State, Zip Code'.$x_prev_empl_city,10);

		$pdf->ezText('Telephone'.$x_prev_empl_phone,10);

		$pdf->ezText('Employed from (mo/yr) '.$x_prev_empl_yr_st.' to '.$x_prev_empl_yr_end,10);

		$pdf->ezText('Pay Start: '.$x_prev_empl_pay_st,10);

		$pdf->ezText('Pay Final: '.$x_prev_empl_pay_end,10);

		$pdf->ezText('Your Title or Position'.$x_prev_empl_title,10);

		$pdf->ezText('Name and Title of Last Supervisor'.$x_prev_empl_super,10);

		$pdf->ezText('Exact Reason for Leaving:',10);

		$pdf->ezText(''.$x_prev_empl_reason,10);

		$pdf->ezText('',10);

		$pdf->ezNewPage();

		$pdf->ezText('Employee Gaps:',10);

		$pdf->ezText(''.$x_emp_gaps,10);

		$pdf->ezText('',10);

		$pdf->ezText('Are you cabable of performing the essantial job duties of the potiion you are being hired for with or without reasonable accomidations? (If not what accomidations would be necessary?',10);

		$pdf->ezText(''.$x_accomplish,10);

		$pdf->ezText('',10);

		$pdf->ezText('I CERTIFY THAT ALL THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TURE AND ACCURATE: '.$x_agree,10);

		$pdf->ezText('',10);

		$pdf->ezText('Digital Signature'.$x_signature,10);

		$pdf->ezText('Date: '.$x_date,10);



	$pdfcode = $pdf->ezOutput();

	$fp=fopen('newhireform.pdf','wb');

	fwrite($fp,$pdfcode);

	fclose($fp);



		// get the form values

		//$x_id = @$HTTP_POST_VARS["x_id"];

		$x_name = @$HTTP_POST_VARS["x_name"];

		$x_pres_addr = @$HTTP_POST_VARS["x_pres_addr"];

		$x_pres_yrs = @$HTTP_POST_VARS["x_pres_yrs"];

		$x_prev_addr = @$HTTP_POST_VARS["x_prev_addr"];

		$x_prev__yrs = @$HTTP_POST_VARS["x_prev__yrs"];

		$x_phone = @$HTTP_POST_VARS["x_phone"];

		$x_ssn = @$HTTP_POST_VARS["x_ssn"];

		$x_q1 = @$HTTP_POST_VARS["x_q1"];

		$x_q1_cmt = @$HTTP_POST_VARS["x_q1_cmt"];

		$x_q2 = @$HTTP_POST_VARS["x_q2"];

		$x_q2_cmt = @$HTTP_POST_VARS["x_q2_cmt"];

		$x_q3 = @$HTTP_POST_VARS["x_q3"];

		$x_q3_cmt = @$HTTP_POST_VARS["x_q3_cmt"];

		$x_pres_empl = @$HTTP_POST_VARS["x_pres_empl"];

		$x_pres_empl_addr = @$HTTP_POST_VARS["x_pres_empl_addr"];

		$x_pres_empl_city = @$HTTP_POST_VARS["x_pres_empl_city"];

		$x_pres_empl_phone = @$HTTP_POST_VARS["x_pres_empl_phone"];

		$x_pres_empl_yr_st = @$HTTP_POST_VARS["x_pres_empl_yr_st"];

		$x_pres_empl_yr_end = @$HTTP_POST_VARS["x_pres_empl_yr_end"];

		$x_res_empl_pay_st = @$HTTP_POST_VARS["x_res_empl_pay_st"];

		$x_pres_empl_pay_end = @$HTTP_POST_VARS["x_pres_empl_pay_end"];

		$x_pres_empl_title = @$HTTP_POST_VARS["x_pres_empl_title"];

		$x_pres_empl_super = @$HTTP_POST_VARS["x_pres_empl_super"];

		$x_pres_empl_reason = @$HTTP_POST_VARS["x_pres_empl_reason"];

		$x_prev_empl = @$HTTP_POST_VARS["x_prev_empl"];

		$x_prev_empl_addr = @$HTTP_POST_VARS["x_prev_empl_addr"];

		$x_prev_empl_city = @$HTTP_POST_VARS["x_prev_empl_city"];

		$x_prev_empl_phone = @$HTTP_POST_VARS["x_prev_empl_phone"];

		$x_prev_empl_yr_st = @$HTTP_POST_VARS["x_prev_empl_yr_st"];

		$x_prev_empl_yr_end = @$HTTP_POST_VARS["x_prev_empl_yr_end"];

		$x_prev_empl_pay_st = @$HTTP_POST_VARS["x_prev_empl_pay_st"];

		$x_prev_empl_pay_end = @$HTTP_POST_VARS["x_prev_empl_pay_end"];

		$x_prev_empl_title = @$HTTP_POST_VARS["x_prev_empl_title"];

		$x_prev_empl_super = @$HTTP_POST_VARS["x_prev_empl_super"];

		$x_prev_empl_reason = @$HTTP_POST_VARS["x_prev_empl_reason"];

		$x_emp_gaps = @$HTTP_POST_VARS["x_emp_gaps"];

		$x_accomplish = @$HTTP_POST_VARS["x_accomplish"];

		$x_agree = @$HTTP_POST_VARS["x_agree"];

		$x_signature = @$HTTP_POST_VARS["x_signature"];

		$x_date = @$HTTP_POST_VARS["x_date"];



		// add the values into an array



		// name

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_name) : $x_name;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`name`"] = $theValue;



		// pres_addr

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_addr) : $x_pres_addr;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_addr`"] = $theValue;



		// pres_yrs

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_yrs) : $x_pres_yrs;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_yrs`"] = $theValue;



		// prev_addr

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_addr) : $x_prev_addr;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_addr`"] = $theValue;



		// prev__yrs

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev__yrs) : $x_prev__yrs;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev__yrs`"] = $theValue;



		// phone

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_phone) : $x_phone;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`phone`"] = $theValue;



		// ssn

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_ssn) : $x_ssn;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`ssn`"] = $theValue;



		// q1

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_q1) : $x_q1;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`q1`"] = $theValue;



		// q1_cmt

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_q1_cmt) : $x_q1_cmt;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`q1_cmt`"] = $theValue;



		// q2

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_q2) : $x_q2;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`q2`"] = $theValue;



		// q2_cmt

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_q2_cmt) : $x_q2_cmt;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`q2_cmt`"] = $theValue;



		// q3

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_q3) : $x_q3;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`q3`"] = $theValue;



		// q3_cmt

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_q3_cmt) : $x_q3_cmt;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`q3_cmt`"] = $theValue;



		// pres_empl

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl) : $x_pres_empl;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl`"] = $theValue;



		// pres_empl_addr

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_addr) : $x_pres_empl_addr;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_addr`"] = $theValue;



		// pres_empl_city

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_city) : $x_pres_empl_city;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_city`"] = $theValue;



		// pres_empl_phone

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_phone) : $x_pres_empl_phone;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_phone`"] = $theValue;



		// pres_empl_yr_st

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_yr_st) : $x_pres_empl_yr_st;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_yr_st`"] = $theValue;



		// pres_empl_yr_end

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_yr_end) : $x_pres_empl_yr_end;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_yr_end`"] = $theValue;



		// res_empl_pay_st

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_res_empl_pay_st) : $x_res_empl_pay_st;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`res_empl_pay_st`"] = $theValue;



		// pres_empl_pay_end

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_pay_end) : $x_pres_empl_pay_end;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_pay_end`"] = $theValue;



		// pres_empl_title

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_title) : $x_pres_empl_title;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_title`"] = $theValue;



		// pres_empl_super

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_super) : $x_pres_empl_super;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_super`"] = $theValue;



		// pres_empl_reason

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_pres_empl_reason) : $x_pres_empl_reason;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`pres_empl_reason`"] = $theValue;



		// prev_empl

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl) : $x_prev_empl;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl`"] = $theValue;



		// prev_empl_addr

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_addr) : $x_prev_empl_addr;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_addr`"] = $theValue;



		// prev_empl_city

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_city) : $x_prev_empl_city;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_city`"] = $theValue;



		// prev_empl_phone

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_phone) : $x_prev_empl_phone;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_phone`"] = $theValue;



		// prev_empl_yr_st

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_yr_st) : $x_prev_empl_yr_st;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_yr_st`"] = $theValue;



		// prev_empl_yr_end

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_yr_end) : $x_prev_empl_yr_end;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_yr_end`"] = $theValue;



		// prev_empl_pay_st

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_pay_st) : $x_prev_empl_pay_st;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_pay_st`"] = $theValue;



		// prev_empl_pay_end

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_pay_end) : $x_prev_empl_pay_end;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_pay_end`"] = $theValue;



		// prev_empl_title

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_title) : $x_prev_empl_title;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_title`"] = $theValue;



		// prev_empl_super

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_super) : $x_prev_empl_super;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_super`"] = $theValue;



		// prev_empl_reason

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_prev_empl_reason) : $x_prev_empl_reason;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`prev_empl_reason`"] = $theValue;



		// emp_gaps

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_emp_gaps) : $x_emp_gaps;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`emp_gaps`"] = $theValue;



		// accomplish

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_accomplish) : $x_accomplish;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`accomplish`"] = $theValue;



		// agree

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_agree) : $x_agree;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`agree`"] = $theValue;



		// signature

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_signature) : $x_signature;

		$theValue = ($theValue != "") ? " '" . $theValue . "'" : "NULL";

		$fieldList["`signature`"] = $theValue;



		// date

		$theValue = (!get_magic_quotes_gpc()) ? addslashes($x_date) : $x_date;

		$theValue = ($theValue != "") ? " '" . ConvertDateToMysqlFormat($theValue) . "'" : "NULL";

		$fieldList["`date`"] = $theValue;



		// insert into database

		$strsql = "INSERT INTO `NewHire` (";

		$strsql .= implode(",", array_keys($fieldList));

		$strsql .= ") VALUES (";

		$strsql .= implode(",", array_values($fieldList));

		$strsql .= ")";

	 	mysql_query($strsql, $conn) or die(mysql_error());

		mysql_close($conn);





		// ************* EMAIL CODE *******************

		// Obtain file upload vars 
		$fileatt      = "newhireform.pdf"; 
		$fileatt_type = "newhireform.pdf"; 
		$fileatt_name = "newhireform.pdf"; 

		$to      = "michaelf@uniqueemployment.com"; // email address to

		$from    = "unique@uniqueemployment.com"; // address from

		$subject = "New Hire Form Submitted";

		$message = "New Hire Form Submitted by: ".$x_name;

		$headers = "From: $from"; 

		  // Read the file to be attached ('rb' = read binary) 
		  $file = fopen($fileatt,'rb'); 
		  $data = fread($file,filesize($fileatt)); 
		  fclose($file); 

		  // Generate a boundary string 
		  $semi_rand = md5(time()); 
		  $mime_boundary = "==Multipart_Boundary_x{$semi_rand}x"; 
   
		  // Add the headers for a file attachment 
		  $headers .= "\nMIME-Version: 1.0\n" . 
		              "Content-Type: multipart/mixed;\n" . 
		              " boundary=\"{$mime_boundary}\""; 
		
		  // Add a multipart boundary above the plain message 
		  $message = "This is a multi-part message in MIME format.\n\n" . 
		             "--{$mime_boundary}\n" . 
		             "Content-Type: text/plain; charset=\"iso-8859-1\"\n" . 
		             "Content-Transfer-Encoding: 7bit\n\n" . 
		             $message . "\n\n"; 

		  // Base64 encode the file data 
		  $data = chunk_split(base64_encode($data)); 

		  // Add file attachment to the message 
		  $message .= "--{$mime_boundary}\n" . 
		              "Content-Type: {$fileatt_type};\n" . 
		              " name=\"{$fileatt_name}\"\n" . 
		              //"Content-Disposition: attachment;\n" . 
		              //" filename=\"{$fileatt_name}\"\n" . 
		              "Content-Transfer-Encoding: base64\n\n" . 
		              $data . "\n\n" . 
		              "--{$mime_boundary}--\n"; 
	 

		// Send the message 
		$ok = @mail($to, $subject, $message, $headers); 

		// ************* END EMAIL CODE *******************



		ob_end_clean();

		header("Location: thankyou.php");

}

?>



<script language="JavaScript" src="ew.js"></script>

<script language="JavaScript">

<!-- start Javascript

function  EW_checkMyForm(EW_this) {

if (EW_this.x_id && !EW_checkinteger(EW_this.x_id.value)) {

        if (!EW_onError(EW_this, EW_this.x_id, "TEXT", "Incorrect integer - id"))

            return false; 

        }

if (EW_this.x_name && !EW_hasValue(EW_this.x_name, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_name, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_addr && !EW_hasValue(EW_this.x_pres_addr, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_addr, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_yrs && !EW_hasValue(EW_this.x_pres_yrs, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_yrs, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_addr && !EW_hasValue(EW_this.x_prev_addr, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_addr, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev__yrs && !EW_hasValue(EW_this.x_prev__yrs, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev__yrs, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_phone && !EW_hasValue(EW_this.x_phone, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_phone, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_ssn && !EW_hasValue(EW_this.x_ssn, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_ssn, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_q1 && !EW_hasValue(EW_this.x_q1, "RADIO" )) {

            if (!EW_onError(EW_this, EW_this.x_q1, "RADIO", "Invalid Field"))

                return false; 

        }

if (EW_this.x_q2 && !EW_hasValue(EW_this.x_q2, "RADIO" )) {

            if (!EW_onError(EW_this, EW_this.x_q2, "RADIO", "Invalid Field"))

                return false; 

        }

if (EW_this.x_q3 && !EW_hasValue(EW_this.x_q3, "RADIO" )) {

            if (!EW_onError(EW_this, EW_this.x_q3, "RADIO", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl && !EW_hasValue(EW_this.x_pres_empl, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_addr && !EW_hasValue(EW_this.x_pres_empl_addr, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_addr, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_city && !EW_hasValue(EW_this.x_pres_empl_city, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_city, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_phone && !EW_hasValue(EW_this.x_pres_empl_phone, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_phone, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_yr_st && !EW_hasValue(EW_this.x_pres_empl_yr_st, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_yr_st, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_yr_end && !EW_hasValue(EW_this.x_pres_empl_yr_end, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_yr_end, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_res_empl_pay_st && !EW_hasValue(EW_this.x_res_empl_pay_st, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_res_empl_pay_st, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_pay_end && !EW_hasValue(EW_this.x_pres_empl_pay_end, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_pay_end, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_title && !EW_hasValue(EW_this.x_pres_empl_title, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_title, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_super && !EW_hasValue(EW_this.x_pres_empl_super, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_super, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_pres_empl_reason && !EW_hasValue(EW_this.x_pres_empl_reason, "TEXTAREA" )) {

            if (!EW_onError(EW_this, EW_this.x_pres_empl_reason, "TEXTAREA", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl && !EW_hasValue(EW_this.x_prev_empl, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_addr && !EW_hasValue(EW_this.x_prev_empl_addr, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_addr, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_city && !EW_hasValue(EW_this.x_prev_empl_city, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_city, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_phone && !EW_hasValue(EW_this.x_prev_empl_phone, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_phone, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_yr_st && !EW_hasValue(EW_this.x_prev_empl_yr_st, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_yr_st, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_yr_end && !EW_hasValue(EW_this.x_prev_empl_yr_end, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_yr_end, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_pay_st && !EW_hasValue(EW_this.x_prev_empl_pay_st, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_pay_st, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_pay_end && !EW_hasValue(EW_this.x_prev_empl_pay_end, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_pay_end, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_title && !EW_hasValue(EW_this.x_prev_empl_title, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_title, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_super && !EW_hasValue(EW_this.x_prev_empl_super, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_super, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_prev_empl_reason && !EW_hasValue(EW_this.x_prev_empl_reason, "TEXTAREA" )) {

            if (!EW_onError(EW_this, EW_this.x_prev_empl_reason, "TEXTAREA", "Invalid Field"))

                return false; 

        }

if (EW_this.x_emp_gaps && !EW_hasValue(EW_this.x_emp_gaps, "TEXTAREA" )) {

            if (!EW_onError(EW_this, EW_this.x_emp_gaps, "TEXTAREA", "Invalid Field"))

                return false; 

        }

if (EW_this.x_accomplish && !EW_hasValue(EW_this.x_accomplish, "TEXTAREA" )) {

            if (!EW_onError(EW_this, EW_this.x_accomplish, "TEXTAREA", "Invalid Field"))

                return false; 

        }

if (EW_this.x_agree && !EW_hasValue(EW_this.x_agree, "RADIO" )) {

            if (!EW_onError(EW_this, EW_this.x_agree, "RADIO", "Invalid Field"))

                return false; 

        }

if (EW_this.x_signature && !EW_hasValue(EW_this.x_signature, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_signature, "TEXT", "Invalid Field"))

                return false; 

        }

if (EW_this.x_date && !EW_hasValue(EW_this.x_date, "TEXT" )) {

            if (!EW_onError(EW_this, EW_this.x_date, "TEXT", "Incorrect date (yyyy/mm/dd) - date"))

                return false; 

        }

if (EW_this.x_date && !EW_checkdate(EW_this.x_date.value)) {

        if (!EW_onError(EW_this, EW_this.x_date, "TEXT", "Incorrect date (yyyy/mm/dd) - date"))

            return false; 

        }

return true;

}



// end JavaScript -->

</script>

<html>
<head>
<link href="css/site.css" rel="stylesheet" type="text/css">
<title>Unique Employment - STAFFING</title>
<script src="js/site.js" type="text/javascript"></script>
</head>
<body bgcolor="#CCCCCC" onLoad="MM_preloadImages('navbar/link1rol.gif','navbar/link2rol.gif','navbar/link3rol.gif','navbar/link4rol.gif','navbar/link5rol.gif','navbar/link6rol.gif','navbar/link7rol.gif','mainimages/main_1.jpg','mainimages/main_2.jpg','mainimages/main_3.jpg','mainimages/main_4.jpg','mainimages/main_5.jpg','mainimages/main_6.jpg','mainimages/main_7.jpg','mainimages/main_8.jpg','mainimages/main_9.jpg','mainimages/main_10.jpg')">
<div align="center">
  <center>
  <table border="0" cellpadding="0" cellspacing="0" width="720">
    <tr>
      <td width="13" height="13" style="background-image: url('images/gspacer.gif');"></td>
      <td width="694" height="13" style="background-image: url('images/ds_top.gif');"></td>
      <td width="13" height="13" style="background-image: url('images/gspacer.gif');"></td>
    </tr>
  </table>
  </center>
</div>

            <!// LEVEL 1 //>

            <div align="center">
              <center>
              <table border="0" cellpadding="0" cellspacing="0" width="720">
                <?php include('level1.php'); ?>
              </table>
              </center>
            </div>

            <!// LEVEL 1 END OF //>

            <!// LEVEL 2 //>

            <div align="center">
              <center>
              <table border="0" cellpadding="0" cellspacing="0" width="720">
                <tr>
                  <td width="720"><?php include('level2.php'); ?></td>
                </tr>
              </table>
              </center>
            </div>

            <!// LEVEL 2 END OF //>

            <!// LEVEL 3 //>

            <div align="center">
              <center>
              <table border="0" cellpadding="0" cellspacing="0" width="720">
                <tr>
                  <td width="720">
                    <?php include('level3.php'); ?>
                  </td>
                </tr>
              </table>
              </center>
            </div>

            <!// LEVEL 3 END OF //>

            <!// LEVEL 4 >

            <div align="center">
              <center>
              <table border="0" cellpadding="0" cellspacing="0" width="720">
                <tr>
                  <td width="720">
                    <?php include('level4.php'); ?>
                  </td>
                </tr>
              </table>
              </center>
            </div>

            <!// LEVEL 4 END OF >

  <div align="center">
    <center>
    <table border="0" cellpadding="0" cellspacing="0" width="720">
      <tr>
        <td width="13" height="3" style="background-image: url('images/ds_left.gif');"></td>
        <td width="172" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="3" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="172" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="3" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="171" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="3" height="3" style="background-image: url('images/cross.gif');"></td>
        <td width="170" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="13" height="3" style="background-image: url('images/ds_right.gif');"></td>
      </tr>
      <tr>
        <td widht="13" height="3" style="background-image: url('images/ds_left.gif');"></td>
        <td width="172" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="3" height="3" style="background-image: url('images/mini_cross.gif');"></td>
        <td width="172" height="3" style="background-image: url('images/horiz_line2.gif');".gif"></td>
        <td width="3" height="3" style="background-image: url('images/mini_cross.gif');"></td>
        <td width="171" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="3" height="3" style="background-image: url('images/cross.gif');"></td>
        <td width="170" height="3" style="background-image: url('images/horiz_line2.gif');"></td>
        <td width="13" height="3" style="background-image: url('images/ds_right.gif');"></td>
      </tr>
    </table>
    </center>
  </div>
  <div align="center">
    <center>
    <table border="0" cellpadding="0" cellspacing="0" width="720">
      <tr>
        <td width="13" height="22" style="background-image: url('images/ds_left.gif');"></td>
        <td width="14" height="22"></td>
        <td width="493" height="22">

<form onSubmit="return EW_checkMyForm(this);"  action="newhireadd.php" method="post">

<p>

<input type="hidden" name="a" value="A">

    Unique PEO New Hire Form (Texas)

  <table width="495" border="0" cellpadding="4" cellspacing="1" bgcolor="#CCCCCC">

    <tr> 

      <td width="441" bgcolor="#F5F5F5">
	    <table width="441" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td><p align="left">First Name</p></td>
          <td><p align="left">Middle Initial</p></td>
          <td><p align="left">Last Name</p></td>
        </tr>
        <tr>
          <td><font size="-1">
            <input type="text" name="x_firstname" size="20" maxlength="250" value="<?php echo htmlspecialchars(@$x_firstname); ?>">
          </font></td>
          <td><font size="-1">
            <input type="text" name="x_lastname" size="2" maxlength="250" value="<?php echo htmlspecialchars(@$x_lastname); ?>">
          </font></td>
          <td><font size="-1">
            <input type="text" name="x_middleinitial" size="20" maxlength="250" value="<?php echo htmlspecialchars(@$x_middleinitial); ?>">
          </font></td>
        </tr>
      </table>        
	    <font size="-1"><br>

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Present Address: (Street, City, State, 

        Zip) <br>

        <input type="text" name="x_pres_addr" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_pres_addr); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">How long have you lived there? (Years, 

        Months) <br>

        <input type="text" name="x_pres_yrs" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_pres_yrs); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><p><font size="-1"> Previous Address: (Street, City, 

          State, Zip)<br>

          <input type="text" name="x_prev_addr" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_prev_addr); ?>">

          </font>&nbsp;</p></td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">How long have you lived there? (Years, 

        Months) <br>

        <input type="text" name="x_prev__yrs" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_prev__yrs); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Phone Number:<br>

        <input type="text" name="x_phone" size="30" maxlength="20" value="<?php echo htmlspecialchars(@$x_phone); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><p><font size="-1">Social Security Number:</font><br>

          <font size="-1"> 

          <input type="text" name="x_ssn" size="30" maxlength="20" value="<?php echo htmlspecialchars(@$x_ssn); ?>">

          </font>&nbsp;</p></td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Have you ever worked for this Company 

        before? <br>

        <?php if (empty($x_q1)) { $x_q1 = "y"; } // set default value ?>

        Yes 

        <input type="radio" name="x_q1"<?php if ($x_q1 == "y") { echo " checked"; } ?> value="<?php echo htmlspecialchars("y"); ?>">

        <?php echo "y"; ?> No 

        <input type="radio" name="x_q1"<?php if ($x_q1 == "n") { echo " checked"; } ?> value="<?php echo htmlspecialchars("n"); ?>">

        <?php echo "n"; ?> </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">If Yes, please give date(s) and position:<br>

        <textarea name="x_q1_cmt" cols="35" rows="4"><?php echo @$x_q1_cmt ?></textarea>

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Have you ever pled guilty, or no 

        contest to, or been convicted of any misdemenor or felony?<br>

        <?php if (empty($x_q2)) { $x_q2 = "y"; } // set default value ?>

        Yes 

        <input type="radio" name="x_q2"<?php if ($x_q2 == "y") { echo " checked"; } ?> value="<?php echo htmlspecialchars("y"); ?>">

        <?php echo "y"; ?> No 

        <input type="radio" name="x_q2"<?php if ($x_q2 == "n") { echo " checked"; } ?> value="<?php echo htmlspecialchars("n"); ?>">

        <?php echo "n"; ?> </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">If Yes, please give date(s) and details:<br>

        <textarea name="x_q2_cmt" cols="35" rows="4"><?php echo @$x_q2_cmt ?></textarea>

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Have you been arrested for any matters 

        for which you are out on bail or on your own recognizance pending trail?<br>

        <?php if (empty($x_q3)) { $x_q3 = "y"; } // set default value ?>

        Yes 

        <input type="radio" name="x_q3"<?php if ($x_q3 == "y") { echo " checked"; } ?> value="<?php echo htmlspecialchars("y"); ?>">

        <?php echo "y"; ?> No 

        <input type="radio" name="x_q3"<?php if ($x_q3 == "n") { echo " checked"; } ?> value="<?php echo htmlspecialchars("n"); ?>">

        <?php echo "n"; ?> </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">If Yes, please give date(s) and details:<br>

        <textarea name="x_q3_cmt" cols="35" rows="4"><?php echo @$x_q3_cmt ?></textarea>

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><p>Note: Answering &quot;Yes&quot; to these questions 

          does not sonstitute an automatic bar to employment. Factors such as 

          age and time of offense, seriousness and nature of the violation, and 

          rehabilitation will be taken into account. (Do not include minor traffic 

          citations and arrests or convictions which have been sealed or expunged 

          in answering this quesitons.</p>

        <p><strong>RECORD OF PREVIOUS EMPLOYMENT</strong></p>

        <p>Please list the names of your previous emplolyers in chronological 

          order with present or last employer listed first. Be sure to account 

          for all periods of time including military service and any period of 

          unemployment. If self-employed, give firm name and supply business refernece 

          under emplyment gaps.</p></td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Present or Last Employer<br>

        <input type="text" name="x_pres_empl" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_pres_empl); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Address<br>

        <input type="text" name="x_pres_empl_addr" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_pres_empl_addr); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">City, State, Zip Code<br>

        <input type="text" name="x_pres_empl_city" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_pres_empl_city); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Telephone<br>

        <input type="text" name="x_pres_empl_phone" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_pres_empl_phone); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Employed from (mo/yr)<br>

        <input type="text" name="x_pres_empl_yr_st" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_pres_empl_yr_st); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">To (mo/yr)<br>

        <input type="text" name="x_pres_empl_yr_end" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_pres_empl_yr_end); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Pay (start)<br>

        <input type="text" name="x_res_empl_pay_st" size="30" maxlength="25" value="<?php echo htmlspecialchars(@$x_res_empl_pay_st); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Pay (final)<br>

        <input type="text" name="x_pres_empl_pay_end" size="30" maxlength="25" value="<?php echo htmlspecialchars(@$x_pres_empl_pay_end); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Your Title or Position<br>

        <input type="text" name="x_pres_empl_title" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_pres_empl_title); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Name and Title of Last Supervisor<br>

        <input type="text" name="x_pres_empl_super" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_pres_empl_super); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Exact Reason for Leaving<br>

        <textarea name="x_pres_empl_reason" cols="35" rows="4"><?php echo @$x_pres_empl_reason ?></textarea>

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Previous Employer<br>

        <input type="text" name="x_prev_empl" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_prev_empl); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Address<br>

        <input type="text" name="x_prev_empl_addr" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_prev_empl_addr); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> City, State, Zip Code<br>

        <input type="text" name="x_prev_empl_city" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_prev_empl_city); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Telephone<br>

        <input type="text" name="x_prev_empl_phone" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_prev_empl_phone); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Employed from (mo/yr)<br>

        <input type="text" name="x_prev_empl_yr_st" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_prev_empl_yr_st); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> To (mo/yr)<br>

        <input type="text" name="x_prev_empl_yr_end" size="30" maxlength="15" value="<?php echo htmlspecialchars(@$x_prev_empl_yr_end); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Pay (start) <br>

        <input type="text" name="x_prev_empl_pay_st" size="30" maxlength="25" value="<?php echo htmlspecialchars(@$x_prev_empl_pay_st); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Pay (final)<br>

        <input type="text" name="x_prev_empl_pay_end" size="30" maxlength="25" value="<?php echo htmlspecialchars(@$x_prev_empl_pay_end); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Your Title or Position<br>

        <input type="text" name="x_prev_empl_title" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_prev_empl_title); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Name and Title of Last Supervisor<br>

        <input type="text" name="x_prev_empl_super" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_prev_empl_super); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><p><font size="-1">Exact Reason for Leaving</font><br>

          <font size="-1"> 

          <textarea name="x_prev_empl_reason" cols="35" rows="4"><?php echo @$x_prev_empl_reason ?></textarea>

          </font>&nbsp;</p></td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><p>Employment Gaps:<br>

          <font size="-1"> 

          <textarea name="x_emp_gaps" cols="35" rows="4"><?php echo @$x_emp_gaps ?></textarea>

          </font>&nbsp;</p></td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1">Are you cabable of performing the 

        essantial job duties of the potiion you are being hired for with or without 

        reasonable accomidations? (If not what accomidations would be necessary?<br>

        <textarea name="x_accomplish" cols="35" rows="4"><?php echo @$x_accomplish ?></textarea>

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> I CERTIFY THAT ALL THE INFORMATION 

        I HAVE PROVIDED ON THIS FORM IS TURE AND ACCURATE<br>

        <?php if (empty($x_agree)) { $x_agree = "y"; } // set default value ?>

        Yes 

        <input type="radio" name="x_agree"<?php if ($x_agree == "y") { echo " checked"; } ?> value="<?php echo htmlspecialchars("y"); ?>">

        <?php echo "y"; ?> No 

        <input type="radio" name="x_agree"<?php if ($x_agree == "n") { echo " checked"; } ?> value="<?php echo htmlspecialchars("n"); ?>">

        <?php echo "n"; ?> </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> Your Digital Signature. Please type 

        your full name.<br>

        <input type="text" name="x_signature" size="30" maxlength="250" value="<?php echo htmlspecialchars(@$x_signature); ?>">

        </font>&nbsp;</td>

    </tr>

    <tr> 

      <td bgcolor="#F5F5F5"><font size="-1"> 

        <?php if (empty($x_date)) { $x_date = "0000-00-00"; } // set default value ?>

        Date<br>

        <input type="text" name="x_date" value="<?php echo FormatDateTime(@$x_date,5); ?>">

        </font>&nbsp;</td>

    </tr>

  </table>

<p>

    <input type="submit" name="Action" value="Submit">

</form>



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              <td width="170" class="news" valign="top"><?php include ('news.php') ?></td>
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        <td width="13" height="3" style="background-image: url('images/ds_left.gif');"></td>
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        <td width="13" height="25" style="background-image: url('images/ds_left.gif');"></td>
        <td width="694" height="25" class="credits"><center>Unique Employment Services 2004 - All Rights Reserved</td>
        <td width="13" height="25" style="background-image: url('images/ds_right.gif');"></td>
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